Parental Form For Dispensing Of Medications In School printable pdf download

MAIN STREET SCHOOL

40 Main Street

Steve Adler, Principal

Denise Raisanen, R.N.

Exeter, N. H. 03833

603-775-8900

Permission form for the dispensing of medications in school

My child, _____________________________ is required by Doctor ___________________________,

the prescribing physician, to take the following medication during school time:

Name of medication: _________________________

Dosage: ______________

Time schedule to be observed:___________________

Method of taking medication: ______________________

Reason for taking medication: ____________________________

Possible adverse reactions:________________________________________________________

Other medication(s) student is taking at this time:_____________________________________

In the event of a medication emergency, please list persons to be notified other than parents and

physician: __________________________________________________________________________

Doctor’s phone #____________________ Parents’ #s __________________________________

Other Emergency Numbers

_____________________________________________________

Prescription medications must be accompanied by a written order from the

prescribing doctor and in a medicine bottle with the prescription label. The medicine

will be delivered, by the parent or guardian, to the school nurse in a pharmacy labeled container

listing the student’s name, the physician’s name, the medicine, and the instructions for this

medication.

Over the counter medication may be given, if needed, with the written request of the

parent/guardian. The medication must be supplied in its original container.

We, the parents, authorize the school nurse or any other member of the staff so designated by

the building principal to assist* our child in taking the above medication. Any pupil in grades

Kindergarten through the twelfth grade must be assisted by such persons, and the medication,

therefore, shall be in the custody of such persons. If the medication is an emergency

medication that must be carried by the student, a written permission form must be in the

nurse’s office. The nurse and the school principal must give sanction for this medication to be

carried by the student.

I, the parent or guardian, agree by signing this request form to the “HOLD HARMLESS”

Statement that follows: I agree that I will not hold liable any member of the school staff who is

directed by me to assist my child in taking the above stated medication.

Assist means having the required medication available to the child as needed and observing the student

as he/she takes or does not take his/her medication.

Parent’s/Guardian Printed Name

___________________________________________

Parent’s/Guardian Signature

_________________________________________

Date____________

Parental Form For Dispensing Of Medications In School

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